Category Archives: Neuroscience

Guest Post: There’s a pelvis… in your brain?!

As an educator, one of my biggest rewards is working with students and clinicians as they learn and grow in the field of pelvic floor physical therapy. This past winter, I was fortunate to work with Amanda Bastien, SPT, a current 3rd year doctoral student at Emory University. Amanda is passionate about helping people, dedicated to learning, and truly just an awesome person to be around, and I am so grateful to have played a small role in her educational journey! Today, I am thrilled to introduce her to all of you! Amanda shares my fascination with the brain and particularly the role it can play when a person is experiencing persistent pain. I hope you all enjoy this incredible post from Amanda! 

Have you ever been told your pain is “all in your head?” Unfortunately, this is often the experience of many people experiencing persistent pelvic pain. Interestingly enough, the brain itself is actually very involved in producing pain, particularly when a person has experienced pain for a long period of time. In this post, I’ll explain to you how someone can come to have pain that is ingrained in their brain, literally, and more importantly, what we can do to help them get better.

Pelvis image

Our brains are incredible! They are constantly changing and adapting; every second your brain fine tunes connections between brain cells, called neurons, reflecting your everyday experiences. This works like a bunch of wires that can connect to one another in different pathways and can be re-routed. Another way to say this is “neurons that fire together, wire together.” This process of learning and adapting with experiences is known as neuroplasticity or neural plasticity. It is a well-documented occurrence in humans and animals. If you’re interested in learning more, this is a great article that summarizes the principles underlying neuroplasticity.1

In the case of pain…. well, here’s where it gets a little complicated.

The brain has distinct physical areas that have been found to relate to different functions and parts of the body.

brain areas

Those two spots in the middle that read “primary motor cortex” and “primary sensory cortex” relate to the control of body movements, and the interpretation of stimulus as sensations like hot, cold, sharp, or dull. By interpretation, I mean the brain uses this area to make sense of the signals it’s receiving from the rest of the body and decides what this feels like. These areas can be broken down by body structure, too.

In this next image, you’re looking at the brain like you’ve cut it down the middle, looking from the back of someone’s head to the front. This image illustrates the physical areas of the brain that correlate to specific limbs and body parts. This representation is known as a homunculus.

homonculus

See how the hand and facial features look massive? That’s because we do a LOT with our hands, have delicate control of our facial expressions, and feel many textures with both. Thus, these areas need a lot of physical space in our brains. In this image, the pelvis takes up less space than other areas, but for people who pay a lot of attention to their pelvis, this area may be mapped differently, or not as well-defined. We know that the brain changes due to experiences, and ordinarily, it has a distinct physical map of structures. But what happens when that brain map is drawn differently with experiences like pain?

Studies suggest that over time, the brain undergoes changes related to long-lasting pain. If someone is often having to pay attention to an area that is painful, they may experience changes in how their brain maps that experience on a day-to-day basis. This varies from person to person, and we’re still learning how this happens. Here’s an example: in a recent study, people experiencing long-standing pelvic pain were found to have more connections in their brains than in those of a pain-free control group, among other findings. The greater the area of pain, the more brain changes were found.2 My point here is to provide you with an example of how the brain can undergo changes with pain that can help explain how strange and scary it can feel for some. Read on to find out how we can work to reverse this!

The process that makes pain occur is complex. It often starts with some injury, surgery, or other experience causing tissue stress. First, cells respond by alerting nerves in the tissues. Then, that signal moves to the spinal cord and the brain, also called the central nervous system. The brain weighs the threat of the stress; neurons communicate with each other throughout the brain, in order to compare the stressor to prior experiences, environments, and emotions. The brain, the commander-in-chief, decides if it is dangerous, and responds with a protective signal in the form of pain.

Pain is a great alarm to make you change what you’re doing and move away from a perceived danger. Over time, however, the brain can over-interpret tissue stress signals as dangerous. Imagine an amplifier getting turned up on each danger signal, although the threat is still the same. This is how tissue stress can eventually lead to overly sensitive pain, even after the tissues themselves are healed.3

Additionally, your brain attempts to protect the area by smudging its drawing of the sensory and motor maps in a process called cortical remapping. Meaning, neurons have fired so much in an area that they rewire and connections spread out. This may be apparent if pain becomes more diffuse, spreads, and is harder to pinpoint or describe. For example, pain starts at the perineum or the tailbone, but over time is felt in a larger area, like the hips, back, or abdomen. To better understand this, I highly recommend watching this video by David Butler from the NOI group.

He’s great, huh? I could listen to him talk all day!

Pain alarms us to protect us, sometimes even when there’s nothing there! After having a limb amputated, people may feel as though the limb is still present, and in pain. This is called phantom limb pain. The limb has changed, but the connections within the brain have not. However, over time the connections in the brain will re-route. I share this example to illustrate how the brain alone can create pain in an area. Pain does not equal tissue injury; the two can occur independently of one another.4 Pain signals can also be created or amplified by thoughts, emotions, or beliefs regarding an injury. Has your pain ever gotten worse when you were stressed?

There is also some older case evidence that describes how chronic pain and bladder dysfunction evolved for people after surgery, in a way that suggests this type of brain involvement.5  Another case study describes a patient with phantom sensations of menstrual cramps following a total hysterectomy! 6

So, can we change the connections that have already re-mapped?

Yes!! The brain is ALWAYS changing, remember? There are clinicians who can help. Physicians have medications that target the central nervous system to influence how it functions. Psychologists and counselors can help people better understand their mental and emotional experiences as they relate to pain, and to work through these to promote health. Physical therapy provides graded exposure to stimuli such as movement or touch, in a therapeutic way that promotes brain changes and improved tolerance to those stimuli that are painful. This can result in a clearer, well-defined brain map and danger signals that are appropriate for the actual level of threat. Physical therapists also help people improve their strength and range of motion, so they can move more, hurt less, and stay strong when life throws heavy things at us!  It is SO important to return to moving normally and getting back to living! Poor movement strategies can prolong pain and dysfunction, and this can turn a short-term stressor into long-lasting, sensitized pain. (See Jessica’s blog here: LINK)

Of course, with any kind of treatment, it also depends on the unique individual. Everyone has personal experiences associated with pain that can make treatment different for them. We are still learning about how neural plasticity occurs, but the brain DOES change. This is how we are all able to adapt to new environments and circumstances around us! Pain is our protective mechanism, but sometimes it can get out of hand. While tissue injury can elicit pain, the nervous system can become overly sensitized to stimulus and cause pain with no real danger. This perception can spread beyond the original problem areas, and this can occur from connections remapping in the brain and the spinal cord. For pelvic pain, treatment is often multidisciplinary, but should include a pelvic health physical therapist who can facilitate tissue healing, optimal movement, and who can utilize the principles of neural plasticity to promote brain changes and return to function.

Amanda_Bastien2Amanda Bastien is a graduate student at Emory University in Atlanta, GA, currently completing her Doctorate of Physical Therapy degree, graduating in May 2018. Amanda has a strong interest in pelvic health, orthopedics, neuroscience and providing quality information and care to her patients. 

References:

  1. Kleim, J.A., Jones, T.A. (2008). Principles of experience-dependent neural plasticity: Implications for rehabilitation after brain damage. Journal of Speech, Language, and Hearing Research, 51, S225-S239. Retrieved from: https://www.jsmf.org/meetings/2008/may/Kleim%20&%20Jones%202008.pdf
  2. Kutch, J. J., Ichesco, E., Hampson, J. P., et al. (2017). Brain signature and functional impact of centralized pain: a multidisciplinary approach to the study of chronic pelvic pain (MAPP) network study. PAIN, 158, 1979-1991.
  3. Origoni, M., Maggiore, U. L. R., Salvatore, S., Candiani, M. (2014). Neurobiological mechanisms of pelvic pain. BioMed Research International, 2014, 1-9. http://dx.doi.org/10.1155/2014/903848
  4. Flor, H., Elbert, T., Knecht, S. et al. (1995). Phantom -limb pain as a perceptual correlate of cortical reorganization following an arm amputation. Nature, 375, 482-484.
  5. Zermann, D., Ishigooka, M., Doggweiler, R., Schmidt, R. (1998) Postoperative chronic pain and bladder dysfunction: Windup and neuronal plasticity – do we need a more neuroulogical approach in pelvic surgery? Urological Neurology and Urodynamics, 160, 102-105.
  6. Dorpat, T.L. (1971) Phantom sensations of internal organs. Comprehensive Psychiatry, 12(1), 27-35.

 

 

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Your Brain is Playing Tricks on You (Part 2): Pain

Ok, before we dive into this post, I wanted to say I am SO sorry for taking so long to get this “Part 2” out there. I was at the American Physical Therapy Association’s Combined Sections Meeting in Anaheim, CA for a week, got home and put a contract down on a new house (YAY!!), and things have just been crazy crazy! So, please accept my apology, and I hope you enjoy this post! Stay tuned for some CSM-y posts in the future!  Thanks for reading!! ~ Jessica 

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“Perhaps it’s time to recognize that the division between mind and body may be no more than a pedagogic device for instructing medical students– and not a useful construct for understanding human health, disease and behavior.”  V.S. Ramachadran, Phantoms in the Brain

Last post, we discussed how the brain can be tricked by both optical illusions and magic tricks. If you haven’t read it yet, you really need to…because it basically sets the stage for our post this week.

So, how does pain play into all of this? 

Well, pain is an output of the brain, much like vision. Meaning, your brain is receiving sensory information from your body (including your mechanosensation, vision, proprioception, hearing, vestibular/balance input, etc), integrating it with your prior knowledge, experiences, emotions and beliefs, and then creating an output. (ie. “This hurts, you better do something about it!” Or, “You just stubbed your toe you baby…you’ll be just fine!” Or, “Oh my gosh! Your back is never going to get better! It’s probably something super serious and dangerous!”).  Just like your brain can sometimes mess with you in relation to your visual input, the same thing can happen with pain. Let’s look at a few examples.

The Phantom Limb

This example ends up being one that is discussed frequently…in fact, much of the current research on pain was inspired by people experiencing phantom limb pain. If you haven’t heard of phantom limb pain before, basically, this is when a person will feel pain in a limb that has been amputated. Crazy, right? We know that clearly the limb itself if not a source of pain, but rather, the brain is still perceiving threat from the area. This can happen for several reasons. One of the main reasons this can occur is that, although the limb itself is gone, the brain will often still have a representation of that limb.

Homunculus

Now, this representation is changeable over time, however, smudging can occur leading to referred sensations from one area to another. This can trick the body into thinking there is a problem with the non-existent hand. Now, normally, you could look down, see your hand, feel it, and that would then confirm for your brain that the hand it actually fine…however, in cases of phantom limb pain, the limb is not there, so reducing the treat becomes much more tricky. The cool thing is, amazing scientists have developed ways to retrain this using things like mirror therapy (Check out this video from David Butler!) and other innovative treatment approaches. So, obviously, I am wayyyy simplifying this phantom limb phenomenon for this blog, and there are other known contributors to phantom limb pain as well, so I really do recommend you read more. Check out this article from Body in Mind which goes into much more detail.

When Perceived Threat and Harm Level Don’t Quite Match

Have you ever had a little splinter that just hurt so much? That you couldn’t get out of your head until is was gone? That’s a little bit of harm…but somehow the brain is perceiving a big problem. Or, have you ever heard a story about a person walking into the ER talking normally with a knife sticking out of their arm? That’s a lot of harm…but somehow the brain is able to perceive a small threat (which is super helpful in that moment so that the person can get to the ER!).

My favorite example of this is Lorimer Moseley’s story of a snake bite in the brush in Australia. Check it out. He’s hilarious and awesome.

Basically, he tells the story of being bitten by a poisonous snake while walking through thick brush in Australia. When the bite occurs, he doesn’t even realize it because his brain at that moment received the bite information and processed it, with the conclusion of “It’s just a stick. There are tons of sticks around here, nothing to worry about.” He doesn’t realize it’s a snake bite until he passes out a while later. Fast forward to a later time, walking through the brush again, feels the same poke and immediately falls down in excruciating pain…only to realize, it was just a stick. Fascinating right? In that second scenario, his brain had the memory of the first snake bite and the trauma from that, thus, the poke felt much more dangerous and threatening than the first time, and he felt a much greater amount of pain.

So, what does this mean for you? 

Basically, just like our brain can be fooled through visual illusions and magicians, we can also be fooled by pain. This is not meant to imply that pain is in your head…but rather, pain can play tricks on you. And what you feel is a problem in your tissues may not actually be a problem there…but rather could be simply the interpretation of your brain based on the information it is receiving in the moment. Pain, just like vision and hearing, is complex. And treating it thus requires a complex and integrative approach.

Wanna learn more? Check out these awesome articles/videos:

Have a wonderful Monday!

~Jessica

 

Your Brain is Playing Tricks on You (Part 1): Visual Illusions

Falling in love is an incredible feeling, isn’t it? One we don’t tend to forget very quickly. At least, that’s how it was for me and Neuroscience. I remember clearly when the falling in love started to take place. Junior year in college, reading a book called  by V.S. Ramachadran, Phantoms in the Brain: Probing the Mysteries of the Human Mind,
for my Neuroanatomy and Physiology of Human Movement class. I remember being glued to that book from cover to cover, only stopping briefly to write down a quick quote or call my parents to tell them the amazing piece of information I just learned (Yes, I still call them to tell them fun things like that :))

The amazing thing, that I’m sure you are realizing too, is that our brains are simply incredible. We have the ability to take in millions of tiny pieces of information in microseconds, integrate it within everything we believe to be true about our world and the universe and then make decisions on what that information means. It’s incredible, really. But did you know that this ultimate perception can lead to misinformation? Did you know your brain can really really mess with you?

Optical Illusions

One of the most well-known tricks of the brain is an optical illusion. Do you see a bunny or a duck?

Illusions DuckBunny

Which square is darker, A or B? (They’re actually the same color!)

128px-Optical_illusion

By Wuhazet – Henryk Żychowski (Own work) [GFDL (http://www.gnu.org/copyleft/fdl.html) or CC BY 3.0 (http://creativecommons.org/licenses/by/3.0)%5D, via Wikimedia Commons

So, how did your brain trick you? Your nervous system is constantly gathering information about the body and the environment through multiple different inputs: visual, mechanical, temperature, proprioceptive (the position of your joints), vestibular (your inner ear). This process is called sensation. Perception, then, is your brain’s interpretation of the information it receives. The brain receives and filters the information from various sensors and then interprets its meaning to create our experience. In these cases, your brain receives the signal (visual input) and then perceives meaning based on the information, and your experience. In the first picture, your brain likely can see either a duck or a bunny depending on how it chooses to interpret the information. In the second one, your brain took into account the shadow that the green cylinder was casting on the board– thus, your brain tricked you into thinking that tile B must be lighter than tile A (although, really they are the same!) And the third one, your brain saw the arrows in the first one as narrowing in the space, and the second as expanding it–even though the lines are the same length. Pretty cool, right?!

Magic Tricks 

I have always loved a good magic trick. I remember seeing my first “real” magic show in Las Vegas at Harrah’s Casino. I was 11 or 12 I think, and was completely mesmerized by Mac King and his comedy magic show. My family just loved it! We were amazed, and couldn’t figure out how he did what he did.

(This is actually pretty close to what that magic show looked and felt like–so enjoy being transported back to 12-year old Jessica’s life!) 

I still love watching a great magic show. From street magicians like David Blaine to bigger than life magicians like David Copperfield or Siegfried and Roy, magicians have the ability to suspend our belief, challenge our perceptions and allow us to believe we are seeing the impossible.

So what are magic tricks? How do they feel so “real” to us watching?

In a way, magic tricks are very similar to optical illusions. Magicians are truly masters at using the brain to fool us into truly seeing something that did not happen. Magic tricks work based on several key principles. First, as we discussed above, your brain constantly creates perceptions based on the sensory inputs it receives from the environment. As was shown in our “illusions” section, the perception does not always directly match the visual input as our brain integrates vision with our previous knowledge, emotions, experiences, etc. to make predictions and ultimately create perception. These predictions are precisely what is exploited during magic tricks. This great article gives the example of the “vanishing ball” trick. In this trick, the magician throws the ball up in the air several times, and finally on the last one, the ball appears to vanish out of the air. But did it really vanish? Of course not! The magician used our brain’s predictions in his favor…thus, we saw the magician continuing to look up toward the ball, we saw the hand move in a “throwing pattern.” and the brain cut a few corners to tell us the ball had been thrown! While we’re busy watching that magician’s face, the ball is then palmed away, and our brain perceives it has vanished! Pretty cool, right? (check out the article for a larger, more detailed explanation!)

Magic tricks also work by confusing our brain with conflicting inputs and playing with our attention. For example, we are much more easily tricked and distracted when we have to multitask and focus on multiple different things at once. This is common with card tricks and other illusions. Emotions (such as humor, story-telling, etc) can also lead to some brain-trickery as it again creates a distraction for the brain, forcing the brain to “predict” to fill in the missing pieces.

It’s really, quite incredible, and learning about all of this actually has made me respect magicians even more as fellow neuroscientists! Check out these excellent articles if you want to dive a little deeper and further understand more of what happens with magic tricks!

Now…You may be thinking… “What the heck Jessica? This is a “pelvic-focused” blog! Why are you writing about optical illusions and magic tricks!?” Well my dear blog reader, you’ll have to find out… Stay tuned for Part 2- Your Brain is Playing Tricks on You: Pain

Mindfulness, Meditation and Pain

“If you get the inside right, the outside will fall into place. Primary reality is within; secondary reality without.” ~ Eckhart Tolle, The Power of Now: A Guide to Spiritual Enlightenment

meditation-338446_1920

Within many traditional clinical practices, mindfulness-based or meditation-based exercises are considered alternative, eastern, touchy-feely or even “voo-doo.” It is often seen as a complementary treatment that may be helpful…but really isn’t going to “treat” the client. I’ve had many clinicians I respect significantly tell me that they don’t use guided meditation within their practice for this exact reason. Respectfully, I have to disagree with that sentiment. I recommend mindfulness-based relaxation or guided meditation to my patients on almost a daily basis, and I believe strongly that there are so many benefits in this practice for a person struggling with persistent pain.

Pain Neuroscience 

To understand why meditation is helpful in overcoming persistent pain, it is crucial to understand what pain is, and to truly grasp the role of the brain in pain (Summary: No brain, no pain). If you are new to this blog, or new to pain science in general, you have a few prerequisites before you move forward:

Ok, I could go on and on…but I won’t. So, we’ll move on.

What is Meditation/Mindfulness Training?  

Mindfulness is described here as a “non-elaborative, non-judgmental awareness of present moment experience.” There are a few different types of mindfulness based meditation practices, usually broken into:

  • Focused Attention: This involves focusing attention on a specific object or sensation (i.e. focusing on breath moving, or focusing on a certain space). If attention is shifted to someone else, the person is then taught to acknowledge it, disengage, and shift the attention back to the object of meditation.
  • Open Monitoring:  This is a non-directed practice of acknowledging any event that occurs in the mind without evaluation or interpretation
  • Variations: There are multiple variations of these practices, usually trending toward one variety or the other. For example, there are guided relaxation exercises which will shift the focus from one body part to another, meditation exercises based on focusing on a color moving through the body, etc.

Meditation and the Brain 

The cool thing is meditation has been found to have some pretty profound effects on the brain. This meta-analysis of fMRI studies aimed to determine how meditation influenced neural activity, and the results were pretty interesting. They found that brain areas from the occipital to frontal lobes were more activated during meditation, specifically areas involved in processing:

  •  self-relevant information (ie. precuneus)
  • self-regulation, problem-solving, and adaptive behavior (ie. anterior cingulate cortex)
  • interoception and monitoring internal body states (ie. insula)
  • reorienting attention (ie. angular gyrus)
  • “experiential enactive self” (ie. premotor cortex and superior frontal gyrus)

Basically, the authors state that all of these areas are characterized by “full attention to internal and external experiences as they occur in the present moment.”

For more information on how meditation impacts the brain, check out this great TEDx talk by Catherine Kerr:

 

Persistent Pain Implications

Now, you may be thinking, why does that matter for a person experiencing persistent pain? Well, it matters because for most people, pain does not solely exist in the present, but rather, is an experience influenced by a complex neural network, integrating 1) what you know about the pain 2) how dangerous you feel it is 3) your history relating to that pain 4) your fears/concerns/worries about the future 5) how this problem relates to your family, job, relationships, home, etc. and 6) so so much more. (including everything helpful and unhelpful your health care providers have told you about your pain.)

Here’s an example. Let’s say you start having some back pain one day after bending over to pick up something off the floor. Happens right? But, what if you used to have back pain years ago and had an MRI that showed degenerative changes in your spine? And what if you have a two year old you have to carry around frequently? What if work has been difficult recently and you’re worried your job is in jeopardy? What if you had a physical therapist tell you that you should never bend down like that or you would “hurt your back?” The amazing thing is that all of these experiences, histories, thoughts, emotions are seamlessly integrated by your brain to determine the immediate “threat level” of your low back, and create an overall pain experience (ultimately, designed to be helpful and protect you against harm).  This story is a real one, and actually happened to a patient of mine…by the time she came into my office, she couldn’t bend forward at all, had severe pain, and was very worried about the level of “damage” in her low back. But, the truth was, she had really just moved in a way that her body chose to guard, and nothing was really “damaged” at all. After a quick treatment session, she was back to full motion without any pain. Now, am I magical in “fixing” backs like that? Yes. But that’s besides the point. But really, all I did was remove the threat level by taking her back to the present moment (ie. Your back is not damaged. Bending is totally fine and functional to do. This is going to get better really soon.) and restore movement to a system that was guarding against it.

So, what does this have to do with meditation/mindfulness? Well, at it’s core, meditation is about changing awareness and improving focus to the present moment. This can then change the “pain story” to decrease the threat level for the present moment, and thus help a person move toward recovery.

Does it work? 

The best part is that it actually seems to make a significant impact (although, of course, we need better larger studies!) Of course, it is just one piece of the puzzle–but I really believe it can be an important component of a comprehensive program to help someone experiencing persistent pain. And, the research actually is trending toward it being beneficial too. In fact, meditation and mindfulness-based stress reduction has been shown to be helpful in reducing pain and improving quality of life in men and women experiencing chronic headaches, chronic low back pain,  and non-specific chronic pain.  There have not been many studies looking specifically at chronic pelvic pain, but there was one pilot study I found, and it also seemed to show favorable results in improving quality of life.  Will it take you 10 years of channeling your inner guru to see the benefits? Actually, the research seems to indicate that changes happen pretty quickly. This study actually found improvements after just four sessions.

Getting Started 

If you are experiencing persistent pain, or are a human who happens to have a brain, you would likely benefit from using meditation as part of your daily exercise program (Yes, I consider meditation exercise!) There are so many fabulous resources out there to get started in practicing mindfulness/meditation. Here are a few of my favorites:

Books that are helpful in understanding meditation:

The Power of Nowby Eckhart Tolle- $10 on Amazon 

Peace is Every Step, by Ticht Naht Han- $8 on Amazon 

Free Guided Meditation Exercises ONLINE/APPS-Note, I find different people tend to enjoy different guided meditations/programs. Try a few different ones here, or even go on to youtube and do a little search. You may find some you love and some you hate, and that really is ok. Try to find what works best for you!

Relax Lite with Andrew Johnson– available free on itunes and as an app!

Breathe to Relax– available free on itunes and as an app!

Headspace– available free on itunes and as an app!

Insight Timer– available free on itunes and as an app!

Sattva Meditation Tracker & Timer- available free on itunes and as an app!

Guided Meditation for Pelvic Pain– by Dustienne Miller, PT, available free on her website.

Tara Brach– Great resources with meditations, lectures, and more!

I hope this is helpful for you! What other resources do you enjoy for relaxation/mindfulness/meditation?  Please feel free to share in the comments below!

Wishing you a very merry Christmas and a happy new year!!

~Jessica